Provider Demographics
NPI:1093773574
Name:NELSON, GARY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:WAYNE
Last Name:NELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S. INGLESIDE DR. #6
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532
Mailing Address - Country:US
Mailing Address - Phone:251-928-1222
Mailing Address - Fax:251-928-2398
Practice Address - Street 1:150 SOUTH INGLESIDE
Practice Address - Street 2:STE 6
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532
Practice Address - Country:US
Practice Address - Phone:251-928-1222
Practice Address - Fax:251-928-2398
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000027793207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000027793Medicaid
AL000027793Medicare ID - Type Unspecified
C74925Medicare UPIN